CODING SHEET HYDROCEPHALUS REIMBURSEMENT. All Medicare information is current as of the time of printing.
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1 CODING SHEET HYDROCEPHALUS REIMBURSEMENT All Medicare information is current as of the January 2014
2 Hydrocephalus ing Coding Options Commonly Billed Codes for Physicians, Hospitals, and Ambulatory Surgery Centers Please Note: The information contained in this document is provided for informational purposes only and represents no statement, promise, or guarantee by Codman Neuro concerning levels of reimbursement, payment, or charge. Similarly, all CPT AMA and HCPCS codes are supplied for informational purposes only and represent no statement, promise, or guarantee by Codman Neuro that these codes will be appropriate or that reimbursement will be made. It is not intended to increase or maximize reimbursement by any payor. We strongly recommend that you consult your payor organization with regard to its reimbursement policies. Current Procedural Terminology 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. All Medicare payment rates are current as of the All products should be used according to their labeling. ICD-9-CM 1 and ICD-10-CM 2 Diagnosis Codes Diagnosis codes are used by both physicians and hospitals to document the indication for the procedure. There are two codes for normal pressure hydrocephalus, depending on its cause. ICD-9-CM Diagnosis Codes Indication Hydrocephalus and normal pressure hydrocephalus (as secondary to another disease process) Issues related to shunt function (other codes are used as the principal diagnosis, NPH is coded as a secondary diagnosis) ICD-9-CM Diagnosis Code Communicating hydrocephalus Idiopathic normal pressure hydrocephalus [INPH] (more commonly used and default code for NPH) Mechanical complication of nervous system device, implant, and graft Infection and inflammatory reaction due to nervous system device, implant, and graft Other complications due to nervous system device, implant, and graft V53.09 Fitting and adjustment of other devices related to nervous system and special senses ICD-10-CM Diagnosis Codes Indication Hydrocephalus and normal pressure hydrocephalus (as secondary to another disease process) Issues related to shunt function (other codes are used as the principal diagnosis, NPH is coded as a secondary diagnosis) ICD-10-CM Diagnosis Code G91.0 Communicating hydrocephalus G91.2 (Idiopathic) normal pressure hydrocephalus [INPH] (more commonly used and default code for NPH) T85.01XA Breakdown (mechanical) of ventricular intracranial (communicating) shunt, initial encounter T85.02XA Displacement of ventricular intracranial (communicating) shunt, initial encounter T85.89XA Other specified complication of internal prosthetic devices, implants and grafts, not elsewhere classified, initial encounter Z46.2 Encounter for fitting and adjustment of other devices related to nervous system and special senses ICD-9-CM Expert for Hospitals Volumes 1, 2, and 3; published by OptumInsight, Inc. (aka Ingenix, Inc.) ICD-10-CM Code Set; January
3 Physician Coding and Reimbursement 3 Current Procedural Terminology (CPT) is copyright 2013 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. Diagnostic Services Procedure CPT Code Description CY 2014 Physician RVU (Facility Setting) * CT, head or brain, without contrast 1.20 CT * CT, head or brain, with contrast * CT, head or brain, without and with contrast 1.81 MRI * MRI, brain, without contrast * MRI, brain, with contrast * MRI, brain, without and with contrast 3.26 Spinal Puncture Spinal puncture, lumbar, diagnostic Spinal puncture, therapeutic, for drainage of CSF 2.45 *Modifier 26 is appended to some codes to indicate that hospital-owned equipment was used so the physician is being reimbursed only for the professional service of interpreting the results. Note: Code is for a routine spinal tap. Code is performed for external or controlled lumbar drainage over the course of several days as an inpatient. Because has a global period of 0 days, the physician can report this code for each day the procedure is performed. Treatment Procedure CPT Code Description CY 2014 Physician RVU (Facility Setting) and Twist drill hole(s) for ventricular puncture for implanting Catheter ventricular catheter 9.04 Implantation Burr hole(s) for implanting ventricular catheter and Creation of shunt; ventriculo-atrial, -jugular, -auricular Replacement Creation of shunt; ventriculo-peritoneal, -pleural, other terminus Replacement or irrigation, ventricular catheter Replacement or revision of CSF shunt, obstructed valve or distal catheter in shunt system Removal of complete CSF shunt system with replacement Adjunctive Services for Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure) 5.45 Removal Removal of complete CSF shunt system without replacement Physician RVUs are based on the Medicare Physician Fee Schedule as published in the Medicare Program: Revisions to Payment Policies under the Physician Fee Schedule for CY 2014 published in the 12/10/2013 Federal Register, and the Pathway to SGR Reform Act of 2013 January
4 Physician Coding and Reimbursement 3 (cont.) Procedure CPT Code Description CY 2014 Physician RVU (Facility Setting) Patency Evaluation Puncture of shunt tubing or reservoir for aspiration or injection procedure ogram for investigation of previously placed shunt 0.68 eg. ventriculoperitoneal Note: Codes and are often used in tandem for evaluating shunt function. Dye is injected (61070) and imaging (75809) is performed to identify any areas of obstruction. Procedure CPT Code Description CY 2014 Physician RVU (Non-Facility Setting) Reprogramming Reprogramming of programmable cerebrospinal shunt 2.41 (Global) CY 2014 Physician RVU (Facility Setting) 1.32 (-26, Professional) Note: Code for reprogramming is typically performed in the physician office. However, it may be performed in the hospital clinic setting. Modifier 26 is appended to show that hospital-owned equipment was used so the physician is being reimbursed only for the professional service. January
5 Hospital Inpatient Coding and Reimbursement The diagnosis and treatment of NPH may result in two separate hospital admissions. The first is for the diagnostic procedure known as external or controlled lumbar drainage. The second admission is for treatment with shunt implantation. Other admissions may later be needed for revisions and other shunt procedures. ICD-9-CM 4 and ICD-10-PCS 5 Procedure Codes Although ICD-9-CM diagnosis codes are used by both physicians and hospitals to document the indication for the procedure, ICD-9-CM procedure codes are for hospital. ICD-9-CM Procedure Codes Service Provided Diagnostic Services Spinal Puncture Treatment Creation of Extracranial Revision, Removal, Irrigation of Ventricular ICD-9-CM Procedure Code Spinal Tap Other diagnostic procedures on spinal cord and spinal canal structures Ventricular shunt to structure in head or neck Ventricular shunt to circulatory system Ventricular shunt to thoracic cavity Ventricular shunt to abdominal cavity and organs Ventricular shunt to urinary system Ventricular shunt to extracranial site NEC Irrigation and exploration of ventricular shunt Replacement of ventricular shunt Removal of ventricular shunt Incision of peritoneum Service Provided Diagnostic Services Spinal Puncture Treatment Creation of Extracranial Revision, Removal, Irrigation of Ventricular ICD-10- PCS Procedure Code 009U[0,3,4]ZX Drainage of Spinal Canal [Open, Percutaneous, or Percutaneous Endoscopic] Diagnostic 0016[0,3]J3 Bypass Cerebral Ventricle to Blood Vessel with Synthetic Substitute[Open, Percutaneous] 0016[0,3]J4 Bypass Cerebral Ventricle to Pleural Cavity with Synthetic Substitute [Open, Percutaneous] 0016[0,3]J6 Bypass Cerebral Ventricle to Peritoneal Cavity with Synthetic Substitute, [Open, Percutaneous] 0016[0,3]J7 Bypass Cerebral Ventricle to Urinary Tract with Synthetic Substitute[Open, Percutaneous] 3C1ZX8Z Irrigation of Indwelling Device using Irrigating Substance, External Approach 00W6[0,3,4]JZ Revision of Synthetic Substitute in Cerebral Ventricle[Open, Percutaneous, Percutaneous Endoscopic] 0DWW[0,3,4]JZ Revision of Synthetic Substitute in Peritoneum [Open, Percutaneous, Percutaneous Endoscopic] 00P6[0,3,4]JZ Removal of Synthetic Substitute from Cerebral Ventricle [Open, Percutaneous, Percutaneous Endoscopic] 0DPW[0,3,4]JZ Removal of Synthetic Substitute from Peritoneum [Open, Percutaneous, Percutaneous Endoscopic] ICD-9-CM Expert for Hospitals Volumes 1, 2, and 3; published by OptumInsight, Inc. (aka Ingenix, Inc.) ICD-10-PCS Code Set January
6 MS-DRG Assignment and Payment 6 Hospital Inpatient Coding and Reimbursement 6 (cont) Under Medicare s hospital inpatient payment system, a single MS-DRG is assigned for the entire hospital stay. The associated payment is all-inclusive and is designed to encompass all services rendered during the stay. Diagnostic Admission: NPH as Principal Diagnosis ICD-9-CM Procedure Code(s) MS- DRG MS-DRG Description MCC= Major Complication/Comorbidity CC= Complication/Comorbidity FY 2014 Medicare 10/1/13 9/30/14 MS-DRG Relative Weight Degenerative nervous system disorders with MCC Degenerative nervous system disorders without MCC Spinal procedures with MCC Spinal procedures with CC or Spinal Neurostimulator Spinal procedures without CC/MCC Treatment Admission: Creation of ICD-9-CM Procedure Code(s) MS- DRG MS-DRG Description MCC= Major Complication/Comorbidity CC= Complication/Comorbidity FY 2014 Medicare 10/1/13 9/30/14 MS-DRG Relative Weight Ventricular shunt procedures with MCC Ventricular shunt procedures with CC Ventricular shunt procedures without CC/MCC Treatment Admission: Other Procedures ICD-9-CM Procedure Codes and are also assigned to MS-DRGs 031 to 033 when NPH, shunt malfunction or attention to the shunt are used as the principal diagnosis. ICD-9-CM Procedure Code has a medical MS-DRG assigned based on the principal diagnosis of NPH, shunt malfunction, or attention to the shunt. ICD-9-CM Procedure Code MS- DRG MS-DRG Description MCC= Major Complication/Comorbidity CC= Complication/Comorbidity Peripheral/cranial nerve and other nervous system procedure with MCC 041 Peripheral/cranial nerve and other nervous system procedure with CC or Peripheral Neurostimulator FY 2014 Medicare 10/1/13 9/30/14 MS-DRG Relative Weight Inpatient national relative weight information is based on the Medicare Inpatient Prospective Payment System as published in the 8/19/13 Federal Register (Medicare Program: Hospital Inpatient Prospective Payment Systems Fiscal Year 2014 Rates; Final Rule) and Rule-CMS-1599-F-Tables.html?DLPage=1&DLSort=0&DLSortDir=ascending. January
7 ICD-9-CM Procedure Code MS- DRG 042 MS-DRG Description MCC= Major Complication/Comorbidity CC= Complication/Comorbidity Peripheral/cranial nerve and other nervous system procedure without CC/MCC FY 2014 Medicare 10/1/13 9/30/14 MS-DRG Relative Weight January
8 Hospital Outpatient Coding and Reimbursement 7 The diagnostic imaging, spinal puncture, a few of the treatment procedures and follow-up services may be performed as outpatient procedures. Service CPT Code APC and Description CY 2014 Medicare Hospital Outpatient Reimbursement APC Weight Status Indicator * Diagnostic CT , CT Without Contrast Q , CT With Contrast Q , CT Without Contrast Followed by Contrast Q3 MRI , MRI/MRA Without Contrast Q , MRI/MRA With Contrast Q , MRI/MRA Without Contrast Followed by Contrast Q3 Spinal Puncture , Level II Nerve Injections T Treatment and follow up & Catheter Implantation Follow-Up Patency Evaluation , Level II Nerve Injections T 0427, Level II Tube or Catheter Changes or Repositioning T , Level II Nerve Procedure T , Level I Tube or Catheter Changes or Repositioning 0261 Level II Plain Film Except Teeth Including Bone Density Measurement T Q2 Reprogramming , Level II Electronic Analysis of Devices S * OPPS Status Indicators Status Indicator Q2 is separately payable in certain circumstances, but designated as packaged when submitted with another code with Status Indicator T. Status Indicator Q3 the service may be part of a composite (combined) APC if billed with certain other services. Status Indicator S the services are paid separately under the APCs and payment rates shown and that payment is always made at 100% of the rate, not reduced even when other separately payable services are also billed. Status Indicator T the service is paid at 50% of rate when billed with another higher-weighted T procedure. Otherwise, it is paid at 100% of the rate. 7 Outpatient Hospital and Ambulatory Surgery Center national reimbursement levels are based on the Medicare Outpatient Prospective Payment System and Ambulatory Surgery Center Payment System as published in Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems Final Rule published in the 12/10/2013 Federal Register January
9 Ambulatory Surgery Center Coding and Reimbursement 7 * ASCs use CPT codes to report outpatient services. Multiple Procedure Discounting indicates that the procedure is subject to a 50% reduction in payment when billed with other procedures. Services CPT Code Description Diagnostic Spinal Puncture Spinal puncture, lumbar, diagnostic Treatment and follow up & Catheter Implantation Follow-Up Patency Evaluation Reprogramming Spinal puncture, therapeutic, for drainage of CSF Replacement or irrigation, ventricular catheter Replacement or revision of CSF shunt, obstructed valve or distal catheter in shunt system Puncture of shunt tubing or reservoir for aspiration or injection ogram for investigation of previously placed shunt eg. ventriculoperitoneal Reprogramming of programmable cerebrospinal shunt CY 2014 Medicare Ambulatory Surgery Center Reimbursement Payment Multiple Procedure Weight Indicator A A A A A2 NA NA N1 reduction does not apply No weight listed P3 ASC Payment Indicators A2 = ASC payment based on an adjusted version of the hospital outpatient weight and payment. N1 = Code is a covered service but is designated as packaged and no separate payment is made. P3 = Procedure is commonly performed in the physician office, ASC payment is based on an adjusted version of the physician fee schedule. * Commercial Insurance Reimbursement for ASCs ASCs should check their commercial payer contracts to be sure that the codes and reimbursement for these procedures have been included. January
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